MCOs: Keeping Track of the Players

How often do the MCOs/HMOs metamorphose? Is it true that they are buying each other out, changing names, and absorbing other MCOs at a faster rate than ever? How many insurance companies is it possible to hide under one umbrella? To how many other companies might you be connected by a contract without ever being aware of it? Is this an attempt to be intentionally obscure? "This has been going on for ten years," says Alison Cherney, president, Cherney & Associates, Brentwood, Tennessee, "but it may be happening more slowly than it was five years ago. There is still consolidation of managed care, but I would say that the pace has slowed down over the past couple of years." Keith Senn, chief operations officer, Center for Orthotic and Prosthetic Care, Louisville, Kentucky, believes that MCOs/HMOs are evolving at largely the same rate they always have. "The smaller ones continue to go out of business or are bought by bigger ones as they fail to compete. Even established companies like Humana can decide to pull up stakes and leave a state if they decide it is an unprofitable market for them." It pays to keep a close eye on everything going on out there, Senn advises. For example, Humana recently quit selling its Medicare replacement plan, turning it over to Anthem. "Stay sharp, keep up," is his earnest advice. "An existing patient may now be covered by Anthem-so we'll have to preauthorize treatment the next time he comes in. And we won't know this until the patient presents his card with the new information." This is why it's important to get preauthorization on all work, he points out-or at least, to verify benefits each time. By looking at the patient's current card, you'll at least know who the patient is currently covered by and what your reimbursement status is likely to be. If you're not sure, call the number on the card and ask, "Are we participating with your plan? Here's our Tax ID number-please check." When a company is bought out, it should be ethically bound to notify its providers, explains Cathie Griffith, president, PrimeCare O&P Network, Ellendale, Tennessee. "However, ethics evidently can be fluid in this business, and there is no legal remedy that I am aware of if MCOs don't notify providers. This is very much related to the silent networking issue, in my opinion." Personnel Changes If it's hard to keep track of the MCOs/TPOs without a scorecard, how much harder is it when their employees change frequently, too? Is this constant migration of contact personnel a clever stratagem, or is it the nature of the business that employees play musical chairs so often? "They always change," says Cherney. "That's just an industry joke. You have to stay on top of them. Every week in our management meetings, we talk about who's changing and what we need to do strategically to stay with them." "Personnel changes are really a headache for everyone," Senn agrees. "You just get comfortable with a phone contact at an insurance company, then they're gone and you have to go through the entire drill again-introducing yourself, explaining your situation as a provider, and developing a good cooperative working relationship. This constant shifting around is really just the nature of the business, however." Keeping up with the MCO scorecard is indeed challenging, but worth the effort in helping you gain contracts. Judith Otto is a freelance writer based in Holly Springs, Mississippi.

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Clinic Manager – Certified Prosthetist Orthotist (CPO) – Rogers, AR

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